Are platelet-rich products necessary during the arthroscopic repair of full-thickness rotator cuff tears: a meta-analysis

Arthroscopic rotator cuff repair combined with platelet-rich plasma products can reduce the rate of retearing and improve clinical outcomes: A meta-analysis of randomized controlled trials

BACKGROUND

Although several studies on the potential benefits of protein-rich plasma (PRP) therapy for rotator cuff injuries have been published, the results have been conflicting. Therefore, this study aimed to determine whether PRP is beneficial for the prevention of retears after arthroscopic rotator cuff repair (ARCR).

METHODS

Two reviewers conducted independent literature searches based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Randomized controlled trials (RCTs) comparing a PRP treatment group with a control group were included. The quality of evidence was assessed using the Cochrane Collaboration Risk of Bias Tool. Clinical outcomes were compared using the risk ratio (RR) for dichotomous variables and weighted mean difference (WMD) for continuous variables. Statistical significance was set at P < .05.

RESULTS

This review included 21 RCTs (1359 patients). Significant results were noted in favor of PRP treatment compared with controls based on retearing rates (16.5% vs 23.6%, respectively; P = .002) and the Constant score in the short term (WMD: 1.98; 95% confidence interval [CI], 0.27-3.70; I2 = 0%; P = .02), medium term and long term (WMD: 2.56 [95% CI: 1.57-3.55]; I2 = 2%; P < .001); the University of California, Los Angeles score in the short term (WMD: 1.14 [95% CI: 0.43-1.85]; I2 = 25%; P = .002) but not in the medium and long term (WMD: 0.66 [95% CI: -0.16 to 1.48]; I2 = 57%; P = .11); and the visual analog scale score in the short term (WMD: -0.63 [95% CI: -0.83 to-0.43]; I2 = 41%; P < .001), medium and long term (WMD: -0.12 [95% CI: -0.19 to-0.05]; I2 = 0%; P = .008). There was no significant difference in American Shoulder and Elbow Surgeons scores between the treatment and control groups in the short term (WMD: -0.48 [95% CI: -2.80 to 1.85]; I2 = 22%; P = .69) or medium and long term (WMD: 0.92 [95% CI: -1.56 to 3.39]; I2 = 40%; P = .47).

CONCLUSION

Intraoperative use of PRP reduces the risk of rotator cuff repair failure, improves clinical outcomes, and reduces recurrence rates.

Evidence analysis on the utilization of platelet-rich plasma as an adjuvant in the repair of rotator cuff tears

BACKGROUND

Platelet-rich plasma has been gaining popularity as an agent for biological augmentation either as the sole treatment modality or as an adjunct to surgical repair. There is substantial discrepancy in the results of the published meta-analyses; and the true efficacy and role of using autologous platelet-rich plasma (PRP) at the time of rotator cuff repair is still ambiguous.

AIM

To performed this systematic overview on the overlapping meta-analyses that analyzed autologous PRP as an adjuvant in the repair of rotator cuff tears and identify the studies which provide the current best evidence on this subject and generate recommendations for the same.

METHODS

We conducted independent and duplicate electronic database searches in PubMed, Web of Science, Scopus, Embase, Cochrane Database of Systematic Reviews, Reference Citation Analysis and the Database of Abstracts of Reviews of Effects on September 8, 2021 to identify meta-analyses that analyzed the efficacy of PRP as an adjuvant in the repair of rotator cuff tears. Methodological quality assessment was made using Oxford Levels of Evidence, AMSTAR scoring and AMSTAR 2 grades. We then utilized the Jadad decision algorithm to identify the study with the highest quality to represent the current best evidence to generate the recommendation.

RESULTS

Twenty meta-analyses fulfilling the eligibility criteria were included. The AMSTAR scores of the included studies varied from 6-10 (mean: 7.9). All the included studies had critically low reliability in their summary of results due to their methodological flaws according to AMSTAR 2 grades. Significant heterogeneity was observed in the reporting of VAS, function outcome scores (long-term UCLA score, ASES score, SST score), operative time and long-term re-tear rates. Recent meta-analyses are more supportive of the role of intra-operative administration of PRPs at the bone-tendon interface in improving the overall healing and re-tear rates, functional outcome and pain. The initial size of the tear and type of repair performed do not seem to affect the benefit of PRPs. Among the different preparations used, leucocyte poor (LP)-PRP possibly offers the greatest benefit as a biological augment in these situations.

CONCLUSION

Based on this systematic overview, we give a level II recommendation that intra-operative use of PRPs at the bone-tendon interface can augment the healing rate, reduce re-tears, enhance functional outcome and mitigate pain in patients undergoing arthroscopic rotator cuff repair. LP-PRP possibly offers the greatest benefit in terms of healing rates, as compared with other platelet preparations.

Limited evidence for biological treatment measures for cartilage and tendon injuries of the shoulder

PURPOSE

To critically review the available literature on the usage of biologics to treat cartilage and tendon injuries of the shoulder.

METHODS

Four different databases were searched in January 2020 for studies reporting data on bone marrow stimulation, autologous chondrocyte implantation, platelet-rich plasma, autologous concentrated serum, and bone marrow aspirate concentrate for the treatment of cartilage and/or tendon injuries of the shoulder. Prospective, retrospective, cohort and case-control studies as well as case series, systematic reviews and laboratory studies (involving human tissue) were included. Cadaveric or animal studies were excluded. Findings were summarized and an expert opinion on trends was provided.

RESULTS

Although there is limited literature available on biologics in cartilage lesions of the shoulder, the advancement from micro- to nanofracture, that is well established for the treatment of cartilage lesions in the knee, may be the next step in the treatment of shoulder lesions as well. The high rate of failure and therefore the complexity of tendon healing following rotator cuff repair has led to a rising interest in biologic augmentation such as platelet-rich plasma and stem cells to enhance tendon-bone-healing and to decrease the prevalence of failure. Despite the increase in publications, there exists a huge heterogeneity of content, quality, and quantity of among studies and their processing methods reporting the use of platelet-rich plasma in rotator cuff repair.

CONCLUSION

Conclusions from individual studies cannot be generalized. Currently, no evidence supports that platelet-rich plasma provides clinical benefits in rotator cuff repair. Similar is reported for microfracture in rotator cuff repair, however, despite no clinical benefits, microfracture has shown to reduce the appearance of structural failures. Although some evidence exists for the use of stem cells form bone marrow aspirate concentrate, results from large case series are still lacking.

LEVEL OF EVIDENCE

Level V.

Platelet-Rich Plasma Augmentation of Arthroscopic Rotator Cuff Repair Lowers Retear Rates and Improves Short-Term Postoperative Functional Outcome Scores: A Systematic Review of Meta-Analyses

Purpose

The purpose of this study is to conduct a systematic review of meta-analyses of rotator cuff repair using platelet-rich plasma (PRP) to identify whether PRP improves clinical function and rate of tendon retears. We will (1) conduct a systematic review of the current meta-analyses of rotator cuff repair using platelet-rich plasma available in the literature, (2) evaluate the quality of these meta-analyses using the Preferred Reporting Items for Systematic Review (PRISMA) methodology, (3) identify whether PRP improves clinical function and rate of tendon retears, and develop guidance to improve future studies in this area.

Methods

We carried out a systematic review of previous meta-analyses published on the clinical outcomes of PRP used in the treatment of rotator cuff tears. We performed a comprehensive search of PubMed, Medline, Cochrane, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase databases, using various combinations of the commercial names of each PRP preparation and “rotator cuff” (with its associated terms), looking specifically at human meta-analysis studies involving the repair of the rotator cuff tendon surgically in the English language. Data validity was assessed and collected on clinical outcomes. Following this, a meta-analysis was undertaken.

Results

Thirteen meta-analyses met the inclusion and exclusion criteria. All were considered of similar quality with Oxman-Guyatt index of 9 and PRISMA score of more than 24. A total of 1,800 patients with an average follow up of 12 to 36 months. The use of PRP for arthroscopic rotator cuff tear, when compared with controls, leads to a lower number of retears, improved short-term postoperative scores, and functional outcome. The following postoperative scores were reported: Constant: 12, Simple Shoulder Test: 10, ASES (American Shoulder and Elbow Surgeons): 9, UCLA (University of California, Los Angeles) 11, SANE (Single Assessment Numeric Evaluation) 1, VAS (visual analog scale): 6, and Retears: 13. Subgroup analysis showed that leukocyte content and gel application make no difference in the effectiveness of PRP. VAS score subgroup analysis showed short-term pain relief.

Conclusions

Our study shows that PRP is effective in reducing retears after rotator cuff repair and improving functional outcome scores and reducing short-term pain.

Level of Evidence

Level III, systematic review of Level I-III studies.

Platelet-Rich Product Supplementation in Rotator Cuff Repair Reduces Retear Rates and Improves Clinical Outcomes: A Meta-analysis of Randomized Controlled Trials

PURPOSE

The purpose of this study was to conduct a comprehensive systematic review and meta-analysis to investigate the clinical and imaging outcomes of all 4 types of platelet-rich therapies (pure platelet-rich plasma [P-PRP], leukocyte and platelet-rich plasma, pure platelet-rich fibrin, and leukocyte and platelet-rich fibrin) in rotator cuff repairs.

METHODS

A systematic literature search was performed to identify rotator cuff tears comparing any of the 4 types of platelet-rich products (PRP) to a control in rotator cuff repair. Data extracted from the studies included retear rates diagnosed with imaging studies, as well as outcome scores such as Constant, American Shoulder and Elbow Surgeons (ASES), University of California Los Angeles (UCLA), Simple Shoulder Test (SST), and visual analog scale (VAS). Meta-analyses compared postoperative outcome scores and retear rates between the control and study groups.

RESULTS

Seventeen studies were included in the meta-analysis. When pooling data from all studies, retear rate for the treatment group was 19.3%, compared to 25.4% for the control group (odds ratio [OR] 0.59, P = .0037). When stratified based on PRP type, only P-PRP resulted in a significant reduction in retear rate (OR 0.26, P = .0005). Overall, treatment with PRP significantly improved Constant scores when compared to controls (mean difference [MD] 2.41, P =.0027), as well as VAS scores (MD -0.12, P = .0014), and SST scores (MD 0.41, P = .0126). There was no significant difference in ASES scores (MD 0.37, P = .7762) or UCLA scores (MD 0.76, P =0.2447) between treatment and controls when pooling data from all studies.

CONCLUSIONS

This analysis demonstrates significant reductions in retear rates when rotator cuff repair is augmented with PRP. P-PRP appears to be the most effective formulation, resulting in significantly improved retear rates and clinical outcome scores when compared with controls.

Application of Platelet-Rich Plasma in Arthroscopic Rotator Cuff Repair: A Systematic Review and Meta-analysis

Background:

It is unclear how and which factors affect the clinical efficacy of platelet-rich plasma (PRP) applied during arthroscopic rotator cuff repair.

Purpose:

To evaluate the clinical efficacy of PRP for arthroscopic repair of full-thickness rotator cuff tear and investigate the factors that affect its clinical efficacy.

Study Design:

Systematic review; Level of evidence, 1.

Methods:

We searched Cochrane Library, EMBASE, MEDLINE, and OVID to identify randomized controlled trials (RCTs) of patients who received PRP treatment and arthroscopic rotator cuff repair (PRP group) versus controls (no-PRP group). The primary outcomes included retear rate, Constant-Murley score, University of California Los Angeles (UCLA) score, short-term American Shoulder and Elbow Surgeons (ASES) score, visual analog scale (VAS) score for pain, and adverse events.

Results:

A total of 14 RCTs were included in this systematic review. Significant improvement in Constant-Murley, UCLA, and VAS pain scores were found in the PRP group during short-term, midterm, and long-term follow-up. The PRP group had a significantly decreased retear rate (risk ratio [RR], 0.57 [95% CI, 0.42 to 0.78]; P = .0003), especially for long-term follow-up (RR, 0.38 [95% CI, 0.17 to 0.83]; P = .02), large to massive tears (RR, 0.58 [95% CI, 0.42 to 0.80]; P = .0008), use of leukocyte-poor PRP (RR, 0.50 [95% CI, 0.33 to 0.76]; P = .001), and intraoperative application of PRP (RR, 0.57 [95% CI, 0.42 to 0.79]; P = .0007). No significant difference between the 2 groups was found in the incidence of adverse events (RR, 1.34 [95% CI, 0.83 to 2.15]; P = .23) or in ASES scores at short-term follow-up (weighted mean difference, 1.04 [95% CI, –3.10 to 5.19]; P = .62).

Conclusion:

The results of this review indicated that arthroscopic rotator cuff repair with PRP significantly reduced the long-term retear rate and shoulder pain and provided improved long-term shoulder function in patients. Intraoperative application of PRP, use of leukocyte-poor plasma, and large to massive tear size contributed to a significantly decreased retear rate for rotator cuff repair combined with PRP.

Biologics to Improve Healing in Large and Massive Rotator Cuff Tears: A Critical Review

Large and massive rotator cuff tears have the highest risk of retear. Common biologic modalities that can potentially reduce the retear rate and improve healing include platelet-rich plasma (PRP), scaffolds, and mesenchymal stem cells (MSCs). PRP has been studied for its role in improving rotator cuff healing and results of randomized controlled trials and meta-analyses show mixed results. Most studies in large and massivge tears show that PRP decreases the retear rate, but the connection between structural integrity and clinical outcomes is still unknown. Extracellular matrix (ECM) and synthetic scaffolds can increase healing in augmentation and bridging repair. Acellular dermal allografts have shown better healing rates and outcomes than xenografts in meta-analyses. Synthetic scaffolds augmented with bone marrow-derived stem cells have only been studied in vitro but are promising for the combination of mechanical stability and induction of a biological response. Superior capsule reconstruction is an exciting type of interposition graft reconstruction that has shown favorable early clinical outcomes for large and massive tears. Bone marrow-derived stem cells and adipose-derived stem cells improve the biomechanical characteristics of tendon repair and enhance the histological findings of the healing process in animal studies. However, evidence from human studies is lacking, especially in patients with large and massive tears. In summary, there are many biological options to augment rotator cuff repair in patients with large and massive tears. Due to mixed results and a lack of standardization in high-quality studies, we cannot recommend PRP at this time as an adjunct to rotator cuff repair. Both ECM and synthetic scaffolds, as well as SCR, can be used, especially in situations where native tendon is compromised, and additional mechanical augmentation is needed. Stem cells have been the least studied to date, so it is difficult to give recommendations for or against their use at this time.

Hip abductor tendon tears: where are we now?

Hip abductor tendon tear is a difficult problem to manage. The hip abductor mechanism is made up of the gluteus medius and minimus muscles, both of which contribute to stabilising the pelvis through the gait cycle. Tears of these tendons are likely due to iatrogenic injury during arthroplasty and chronic degenerative tendinopathy. Ultrasound and magnetic resonance imaging have provided limited clues regarding the pattern of disease and further work is required to clarify both the macro and microscopic pattern of disease. While surgery has been attempted over the last 2 decades, the outcomes are variable and the lack of high-quality studies have limited the uptake of surgical repair. Hip abductor tendon tears share many features with rotator cuff tears, hence, innovations in surgical techniques, materials and biologics may apply to both pathologies.

Arthroscopic Rotator Cuff Repair: A Systematic Review of Overlapping Meta-Analyses

BACKGROUND

Rotator cuff tears are a common pathology, with an increasing number of repairs being performed arthroscopically. The purpose of this study was to systematically review the results in the current meta-analyses on arthroscopic rotator cuff repair, looking specifically at double-row repair compared with single-row repair, at whether platelet-rich plasma should be used adjunctively at the time of the surgical procedure, and at the effects of early-motion compared with late-motion rehabilitation postoperatively.

METHODS

MEDLINE, Embase, and the Cochrane Library were screened for meta-analyses on arthroscopic rotator cuff repair. The levels and quality of the evidence were assessed, and the clinical outcomes were evaluated. A significant result was defined as p < 0.05.

RESULTS

Twenty-four meta-analyses were identified, with 10 meta-analyses on double-row repair compared with single-row repair, 7 meta-analyses on platelet-rich plasma compared with a control, and 7 meta-analyses on early motion compared with late motion. Studies found a significant result in terms of reduced retear rates and/or increased tendon-healing rate for double-row repair (6 of 10 studies; p < 0.05), without a clinically important improvement in functional outcomes (0 of 10 studies). There was a favorable outcome when using platelet-rich plasma in small-to-medium tears in terms of a reduced rate of retear (4 of 4 studies; p < 0.05). However, in the 1 study in which platelet-rich plasma was stratified into pure platelet-rich plasma and platelet-rich fibrin matrix preparation, there was a significantly lower retear rate for tears of all sizes with platelet-rich plasma and not with platelet-rich fibrin (p < 0.05). Range of motion was shown to be significantly better with early motion (5 of 6 studies; p < 0.05) in the majority of the meta-analyses, without an increased risk of retear (6 of 6 studies; p > 0.05).

CONCLUSIONS

The highest Level of Evidence and the highest-quality studies all supported the use of double-row repair, adjunctive platelet-rich plasma, and early-motion rehabilitation postoperatively in arthroscopic rotator cuff repair.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Efficacy of platelet-rich plasma for non-transfusion use: Overview of systematic reviews

INTRODUCTION

Platelet-rich plasma (PRP) is a blood component therapy with a supraphysiological concentration of platelets derived from allogenic or, more commonly, autologous blood. PRP has been used in different non-transfusion indications because of its role in the promotion of tissue repair and healing, in fields such as Traumatology, Dermatology and Dentistry.

OBJECTIVE

To provide a synthesis of the efficacy of PRP for different clinical situations.

METHODS

Systematic searches were carried out in MEDLINE, Embase, Cochrane Library and LILACS in July 2018 to identify systematic reviews (SRs) of randomized clinical trials (RCTs) focusing on PRP for non-transfusion use. Two authors independently screened all retrieved references in two stages (titles and abstracts at a first stage and full texts at a second stage). The methodological quality of SRs that met the eligibility criteria was appraised by AMSTAR 2. Conclusions were based on the most recent SRs with highest quality.

RESULTS

One thousand two hundred and forty references were retrieved. After checking the inclusion criteria, 29 SRs of RCTs related to three different fields (wound care, Orthopedics and Dentistry) were included. The results suggest the benefit of PRP for different clinical situations, such as diabetic wounds, acute lesions of musculoskeletal system, rotator cuff lesions, tendinopathies, knee and hip osteoarthritis, total knee arthroplasty, allogenic bone graft for dental implants and periodontal intrabony defects.

CONCLUSION

There is low to moderate quality evidence supporting the efficacy of PRP for specific clinical situations. The low quality of the evidence limits the certainty of these findings. Well-planned and well-conducted RCTs are still needed to further assess the efficacy of PRP.

Clinical efficacy and safety of platelet-rich plasma in arthroscopic full-thickness rotator cuff repair: A meta-analysis

BACKGROUND

Arthroscopic repair of rotator cuff tears, although commonly performed, carries the risk of retears. Therefore, bioremediation techniques such as platelet-rich plasma injections have been used as adjuvant therapies. The clinical efficacy of platelet-rich plasma in the arthroscopic repair of full-thickness rotator cuff injury is controversial. We performed a meta-analysis to evaluate the clinical effectiveness and safety of platelet-rich plasma and provide evidence-based medical recommendations for selecting the proper clinical treatment plan for full-thickness rotator cuff injuries.

METHODS

A search for the terms "platelet-rich plasma" and "rotator cuff" was performed in the PubMed, EMBASE, and Cochrane Library databases using a computer. After conducting quality evaluations and data extraction, RevMan 5.3 software was used to combine the effect sizes, and the GRADEpro Guideline Development Tool was used to rate the level of evidence from aspects of functional score, pain score and retear rate.

RESULTS

Eight randomized controlled trials involving 566 patients were included. The long-term retear rate(RR = 0.96, 95% CI [0.52, 1.78], P = .89), Constant score(RR = 0.96, 95% CI [0.52, 1.78], P = .89), and Visual Analog Scale score for pain (SMD = -0.28, 95% CI [-0.60, 0.04], P = .08), as well as both the long-term and short-term Disabilities of the Arm, Shoulder, and Hand scores(SMD = -0.13, 95% CI [-0.44, 0.18], P = .41;SMD = -0.02, 95% CI [-0.40, 0.36], P = .93), were not significantly different between the platelet-rich plasma and control groups. However, the short-term retear rate(RR = 0.29, 95% CI [0.13, 0.65], P = .003) and Visual Analog Scale score (SMD = -0.41, 95% CI [-0.62, -0.19], P = .0002) were significantly lower, while the short-term Constant score(SMD = 0.37, 95% CI [0.19, 0.55], P < .0001) and short-term and long-term University of California at Los Angeles activity scores (SMD = 0.38, 95% CI [0.16, 0.60], P = .0008;SMD = 0.85, 95% CI [0.48, 1.22], P < .00001) were significantly higher, in the platelet-rich plasma group than in the control group.

CONCLUSION

Platelet-rich plasma injection can effectively improve the short-term outcomes following arthroscopic repair of full-thickness rotator cuff tears, thus reducing the rate of retears, alleviating pain, and improving patients' shoulder function. Specifically, the clinical outcomes are better with the use of platelet-rich plasma in single-row fixation than in other fixation techniques. Therefore, platelet-rich plasma injection can be recommended as an adjuvant therapy in single-row repair for improved short-term results.

Is platelet-rich plasma an ideal biomaterial for arthroscopic rotator cuff repair? A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Recently, many authors have reported the effects of platelet-rich plasma (PRP) on rotator cuff repair. Whether PRP treatment during arthroscopic rotator cuff repair improves tendon healing rates or restores full function remains unknown. The purpose of this meta-analysis was to evaluate the clinical improvement and radiological outcomes of PRP treatment in patients undergoing arthroscopic rotator cuff repair.

METHODS

PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials were searched. The study included only level 1 or 2 randomized controlled trials (RCTs) that compared the injection of platelet-rich plasma or platelet-rich fibrin matrix. The methodological quality of the trials was assessed using the Cochrane Handbook for Systematic Reviews of Interventions, 5.3. Continuous variables were analysed using the weighted mean difference, and categorical variables were assessed using relative risks. P < 0.05 was considered statistically significant.

RESULTS

The meta-analysis revealed a lower retear rate following PRP treatment than that following the control method (mean difference, 1.10; 95% CI, 1.03 to 1.18; P = 0.004). Constant shoulder scores improved with PRP (mean difference, 2.31; 95% CI, 1.02 to 3.61; P = 0.0005). PRP treatment also resulted in higher UCLA scores (mean difference, 0.98; 95% CI, 0.27 to 1.69; P = 0.007), and simple shoulder test scores were improved (mean difference, 0.43; 95% CI, 0.11 to 0.75; P = 0.008). Finally, lower visual analogue scale scores were observed with PRP augmentation (mean difference, - 0.35; 95% CI, - 0.57 to - 0.13; P = 0.002).

CONCLUSIONS

The current systematic review and meta-analysis reveals that PRP treatment with arthroscopic repair of rotator cuff tears decreases the retear rate and improves the clinical outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016048416.

Bone marrow stimulation decreases retear rates after primary arthroscopic rotator cuff repair: a systematic review and meta-analysis

BACKGROUND

Despite the optimization of biomechanical and patient factors in the setting of rotator cuff repair (RCR), postoperative retear rates remain high in many series reported in the literature. Preclinical studies have suggested bone marrow stimulation (BMS) at the rotator cuff footprint may reduce the rate of retear after RCR. The objective of this meta-analysis was to analyze the clinical evidence investigating the effect of arthroscopic RCR, with and without BMS, on rotator cuff healing and functional outcomes.

METHODS

PubMed, MEDLINE, Embase, and the Cochrane Library were searched through December 2017. Two reviewers selected studies based on the inclusion criteria and assessed methodologic quality. Pooled analyses were performed for continuous and binomial variables where appropriate.

RESULTS

Four studies (365 patients), including 2 Level I randomized controlled trials and 2 Level III retrospective comparative cohort studies were included. There was no statistical difference in the Disabilities of the Arm, Shoulder and Hand score, University of California Los Angeles Shoulder Rating Scale score, or the Constant score between the BMS and conventional repair groups. The pooled retear rates were 18.4% (28 of 152) and 31.8% (56 of 176) for patients treated with and without BMS, respectively. The pooled analysis of rotator cuff retear rates from the 4 studies (328 patients) showed a statistically significant difference favoring BMS over conventional repair (odds ratio, 0.42; 95% confidence interval, 0.25-0.73; P = .002; I² = 0%).

CONCLUSION

BMS reduces the retear rate after RCR but shows no difference in functional outcomes compared with conventional repair. This study provides evidence for the use of BMS as a potential cost-effective biological approach toward improving rotator cuff healing.

The Efficacy of Platelet-Rich Plasma and Platelet-Rich Fibrin in Arthroscopic Rotator Cuff Repair: A Meta-analysis of Randomized Controlled Trials

BACKGROUND

Basic science studies suggest that platelet-rich therapies have a positive effect on tendon repair. However, the clinical evidence is conflicted on whether this translates to increased tendon healing and improved functional outcomes.

PURPOSE

To perform a systematic review of randomized controlled trials (RCTs) in the literature to ascertain whether platelet-rich plasma (PRP) or platelet-rich fibrin (PRF) improved patient outcomes in arthroscopic rotator cuff repair.

STUDY DESIGN

Meta-analysis.

METHODS

Two independent reviewers performed the literature search based on the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with a third author resolving any discrepancies. RCTs comparing PRP or PRF to a control in rotator cuff repair were included. Quality of evidence was assessed using the Jadad score. Clinical outcomes were compared using the risk ratio for dichotomous variables and the mean difference for continuous variables. A P value <.05 was deemed statistically significant.

RESULTS

Eighteen RCTs with 1147 patients were included in this review. PRP resulted in significantly decreased rates of incomplete tendon healing for all tears combined (17.2% vs 30.5%, respectively; P < .05), incomplete tendon healing in small-medium tears (22.4% vs 38.3%, respectively; P < .05), and incomplete tendon healing in medium-large tears (12.3% vs 30.5%, respectively; P < .05) compared to the control. There was a significant result in favor of PRP for the Constant score (85.6 vs 83.1, respectively; P < .05) and the visual analog scale score for pain at 30 days postoperatively (2.9 vs 4.3, respectively; P < .05) and at final follow-up (1.2 vs 1.4, respectively; P < .05) compared to the control. PRF did not result in a significantly decreased rate of incomplete tendon healing for all tears combined (23.0% vs 24.6%, respectively; P = .74) or an improved Constant score (80.8 vs 79.8, respectively; P = .27) compared to the control. PRF resulted in a significantly longer operation time (99.1 vs 83.3 minutes, respectively; P< .05) compared to the control.

CONCLUSION

The current evidence indicates that the use of PRP in rotator cuff repair results in improved healing rates, pain levels, and functional outcomes. In contrast, PRF has been shown to have no benefit in improving tendon healing rates or functional outcomes.

The effect of autologous platelet rich plasma on tenocytes of the human rotator cuff

Background

Platelet rich plasma (PRP) is widely used in rotator cuff repairs but its effect on the healing process is unclear. Several cell culture studies on the effect of allogenic PRP have reported promising results but are not transferable to clinical practice.

The aim of the present study is to assess the possible effect of autologous PRP on rotator cuff tendon cells. The amount of growth factors involved with tendon-bone healing (PDGF-AB, IGF-1, TGF-β1, BMP-7 and -12) is quantified.

Methods

Rotator cuff tissue samples were obtained from (n = 24) patients grouped by age (>/< 65 years) and sex into four groups and cells were isolated and characterized. Later, autologous PRP preparations were obtained and the effect was analyzed by means of cell proliferation, collagen I synthesis and expression of collagen I and III. Furthermore, the PRPs were quantified for growth factor content by means of platelet-derived growth factor (PDGF-AB), insulin-like growth factor (IGF-1), transforming growth factor (TGF-β1), as well as bone morphogenetic protein (BMP) -7 and − 12.

Results

Cell proliferation and absolute synthesis of collagen I were positively affected by PRP exposure compared to controls (p < 0.05), but expression and relative synthesis of collagen I (normalized to cell proliferation) were significantly reduced.

PRP contained high amounts of IGF-1 and lower levels of TGF-β1 and PDGF-AB. The amounts of BMP-7 and -12 were below the detection limits.

Conclusions

PRP is a source of growth factors such involved with tendon-bone healing. PRP had an anabolic effect on the human rotator cuff tenocytes of the same individual in vitro by means of cell proliferation and absolute, but not relative collagen I synthesis.

These results encourage further studies on clinical outcomes with more comparable standards in terms of preparation and application methods.

Level of evidence

Controlled laboratory study.

A Systematic Summary of Systematic Reviews on the Topic of the Rotator Cuff

BACKGROUND

The number of systematic reviews and meta-analyses published on the rotator cuff (RC) has increased markedly.

PURPOSE

To quantify the number of systematic reviews and meta-analyses published on the RC and to provide a qualitative summary of the literature.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic search for all systematic reviews and meta-analyses pertaining to the RC published between January 2007 and September 2017 was performed with PubMed, MEDLINE, and the Cochrane Database of Systematic Reviews. Narrative reviews and non-English language articles were excluded.

RESULTS

A total of 1078 articles were found, of which 196 met the inclusion criteria. Included articles were summarized and divided into 15 topics: anatomy and function, histology and genetics, diagnosis, epidemiology, athletes, nonoperative versus operative treatment, surgical repair methods, concomitant conditions and surgical procedures, RC tears after total shoulder arthroplasty, biological augmentation, postoperative rehabilitation, outcomes and complications, patient-reported outcome measures, cost-effectiveness of RC repair, and quality of randomized controlled trials.

CONCLUSION

A qualitative summary of the systematic reviews and meta-analyses published on the RC can provide surgeons with a single source of the most current literature.

[Arthroscopic rotator cuff surgery : New and established methods]

This present article summarizes established and current developments and aspects of rotator cuff surgery. Achieved milestones as well as current approaches are presented and assessed with respect to their clinical and radiographic impact. Despite biomechanical and technical improvements in modern rotator cuff repair techniques, re-defect and re-tearing rates could not be fully eliminated. Meanwhile, the importance of biological processes around successful tendon-bone reintegration has been increasingly recognized. Hence, this article presents the current scientific standing regarding biological growth factors, platelet-rich plasma and rotator cuff augmentation techniques (with allogenic/autologous grafts). In summary, there are clear biomechanical advantages as well as many promising approaches to biological augmentation; however, the latter have not yet been transferred into regular clinical application.

The effect of subacromial injections of autologous conditioned plasma versus cortisone for the treatment of symptomatic partial rotator cuff tears

PURPOSE

Rotator cuff tears are one of the most common causes of shoulder malfunction and pain, which lead to a significant reduction in the quality of life. This present study investigated the effects of subacromial platelet-rich plasma injections [i.e. autologous conditioned plasma (ACP) injections] as compared to standard subacromial cortisone injection therapy in 50 patients with partial rotator cuff tears.

METHODS

Before injection, and 6 weeks, 12 weeks and 6 months thereafter, the patients were assessed by the Constant-Murley score (CMS), the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), the simple shoulder test (SST) and a pain visual analogue scale (VAS). An MRI was also performed before and 6 months after injection.

RESULTS

Both patient groups had statistically significant better shoulder score outcomes over time. ASES, SST and CMS outcomes after 12 versus 6 weeks were better in the ACP group as compared to the cortisone group. VAS, ASES and CMS outcomes after 12 weeks versus baseline in the ACP group were better as compared to the cortisone group. There was a statistically significant difference between ACP group and cortisone group 12 weeks after injection regarding VAS, ASES, SST and CMS in favour of the ACP group. The MRI showed an improvement in grade of tendinopathy in both groups, however, without statistically significant differences between the two groups.

CONCLUSION

Compared with cortisone injections, ACP injections show earlier benefit as compared to cortisone injections although a statistically significant difference after 6 months could not be found. Therefore, subacromial ACP injections are a good alternative to subacromial cortisone injections, especially in patients with contraindication to cortisone.

LEVEL OF EVIDENCE

Therapeutic study, Level III.

Rotator cuff rehabilitation: current theories and practice

A fully functioning, painless shoulder joint is essential to maintain a healthy, normal quality of life. Disease of the rotator cuff tendons (RCTs) is a common issue that affects the population, increasing with age, and can lead to significant disability and social and health costs. RCT injuries can affect younger, healthy patients and the elderly alike, and may be the result of trauma or occur as a result of chronic degeneration. They can be acutely painful, limited to certain activities or completely asymptomatic and incidental findings. A wide variety of treatment options exists ranging from conservative local and systemic pain modalities, to surgical fixation. Regardless of management ultimately chosen, physiotherapy of the RCT, rotator cuff muscles and surrounding shoulder girdle plays an essential role in proper treatment. Length of treatment, types of therapy and timing may vary if therapy is definitive care or part of a postoperative protocol. Allowing time for adequate RCT healing must always be considered when implementing ROM and strengthening after surgery. With current rehabilitation methods, patients with all spectrums of RCT pathology can improve their function, pain and quality of life. This manuscript reviews current theories and practice involving rehabilitation for RCT injuries.

Effects of Platelet-Rich Plasma (PRP) on a Model of Renal Ischemia-Reperfusion in Rats

Renal ischemia-reperfusion injury is a major cause of acute renal failure, causing renal cell death, a permanent decrease of renal blood flow, organ dysfunction and chronic kidney disease. Platelet-rich plasma (PRP) is an autologous product rich in growth factors, and therefore able to promote tissue regeneration and angiogenesis. This product has proven its efficacy in multiple studies, but has not yet been tested on kidney tissue. The aim of this work is to evaluate whether the application of PRP to rat kidneys undergoing ischemia-reperfusion reduces mid-term kidney damage. A total of 30 monorrenal Sprague-Dawley male rats underwent renal ischemia-reperfusion for 45 minutes. During ischemia, PRP (PRP Group, n = 15) or saline solution (SALINE Group, n = 15) was administered by subcapsular renal injection. Control kidneys were the contralateral organs removed immediately before the start of ischemia in the remaining kidneys. Survival, body weight, renal blood flow on Doppler ultrasound, kidney weight, kidney volume, blood biochemistry and histopathology were determined for all subjects and kidneys, as applicable. Correlations between these variables were searched for. The PRP Group showed significantly worse kidney blood flow (p = 0.045) and more histopathological damage (p<0.0001). Correlations were found between body weight, kidney volume, kidney weight, renal blood flow, histology, and serum levels of creatinine and urea. Our study provides the first evidence that treatment with PRP results in the deterioration of the kidney’s response to ischemia-reperfusion injury.

Subacromial injection of autologous platelet-rich plasma versus corticosteroid for the treatment of symptomatic partial rotator cuff tears

OBJECTIVE

Rotator cuff tears are one of the most common causes of chronic shoulder pain and disability. They significantly affect the quality of life. Reduced pain and improved function are the goals of conventional therapy, which includes relative rest, pain therapy, physical therapy, corticosteroid injections and surgical intervention. Tendons have a relative avascular nature; hence, their regenerative potential is limited. There is some clinical evidence that the application of autologous platelets may help to revascularize the area of injury in rotator cuff pathologies.

PATIENTS AND METHODS

This prospective randomized controlled study was done to evaluate the results of subacromial injection of platelet-rich plasma (PRP) versus corticosteroid injection therapy in 40 patients with symptomatic partial rotator cuff tears. All patients were assessed before injection, 6 weeks, 3 and 6 months after injection, using the American Shoulder and Elbow Surgeons Standardized Shoulder Assessment Form (ASES), the Constant-Murley Score (CMS), the Simple Shoulder Test (SST) and a Visual Analog Scale (VAS) for pain. An MRI was performed before and 6 months after the injection for all the included patients and was graded on 0-5 scale.

RESULTS

Both injection groups showed statistically significantly better clinical outcomes over time compared with those before injection. There was a statistically significant difference between RPP group and corticosteroid group 12 weeks after injection, regarding VAS, ASES, CMS and SST in favor of the RPP group. MRI showed an overall slight nonsignificant improvement in grades of tendinopathy/tear in both groups, however, without statistically significant differences between the two groups.

CONCLUSION

PRP injections showed earlier better results as compared to corticosteroid injections, although statistically significant better results after 6 months could not be found. Therefore, subacromial RPP injection could be considered as a good alternative to corticosteroid injection, especially in patients with a contraindication to corticosteroid administration.

LEVEL OF EVIDENCE

II.

Platelet-Rich Plasma in a Murine Model: Leukocytes, Growth Factors, Flt-1, and Muscle Healing

BACKGROUND

It is well known that platelet-rich plasma (PRP) preparations are not the same and that not all preparations include white blood cells, but the part that leukocytes play on the healing role of PRP is still unknown.

PURPOSE

The primary aim of this study was to evaluate the influence of leukocytes in different PRP preparations with a special emphasis on growth factor concentrations. The secondary aim was to evaluate the influence of PRP on muscle healing.

STUDY DESIGN

Controlled laboratory study.

METHODS

Two PRP preparation procedures were evaluated. Blood fractions were stained with Rapid Panoptic, and growth factors (transforming growth factor beta 1 [TGF-β1], vascular endothelial growth factor [VEGF], insulin-like growth factor [IGF], epidermal growth factor [EGF], hepatocyte growth factor [HGF], and platelet-derived growth factor [PDGF]) were quantified by enzyme-linked immunosorbent assay. Western blotting analysis was performed for Fms-related tyrosine kinase 1 (Flt-1). A muscle contusion injury was created and treated with PRP at different time points.

RESULTS

Leukocytes were the main source of VEGF, and all other growth factors measured had a higher concentration in the preparations that included the buffy coat and consequently had a higher concentration of white blood cells. Flt-1 was also found in platelet-poor plasma (PPP). There were higher concentrations of PDGF and HGF in the preparations that encompassed the buffy coat. A PRP injection 7 days after the injury provided significantly increased exercise performance and decreased the fibrotic area when compared with other PRP-treated groups.

CONCLUSION

VEGF is only present in PRP's buffy coat, while Flt-1 is present in PPP. A PRP injection 7 days after an injury resulted in improved exercise performance.

CLINICAL RELEVANCE

The presence of Flt-1 in PRP provides yet another explanation for results described in the literature after a PRP injection. This information is relevant for selecting the best PRP for each type of injury.

Effect of platelet-rich plasma with self-assembled peptide on the rotator cuff tear model in rat

Several trials have been carried out to improve the healing of rotator cuff tear, but their effects remain controversial. In this study, we examined the therapeutic effect of platelet-rich plasma (PRP) in combination with self-assembled peptide (SAP) on the healing of rotator cuff tear in the rat. Twenty-seven Sprague-Dawley rats, aged 15 weeks, were used for the rotator cuff tear model. The supraspinatus muscle at the insertion site was dissected and truncated, leaving the cut edge free. A week after the surgery, the rats were randomly divided into SAP, PRP, SAP-PRP and control groups and 0.2 ml SAP, PRP, SAP-PRP and saline were injected, respectively. Bonar scores and synovial inflammation grade were checked 5 weeks after the injection. Immunofluorescence staining for heat shock protein (HSP)-70 and caspase-3 was conducted. Furthermore, maximum stride length was measured before and at 2 and 4 weeks after the injection. The Bonar scores were 6.4 ± 1.8 in the SAP group, 5.9 ± 2.0 in the PRP group, 4.7 ± 1.1 in the SAP-PRP group and 8.3 ± 2.3 in the control group. There was significant difference between the SAP-PRP and control groups in post hoc multiple comparison analysis. Among four categories of Bonar scores, collagen arrangement and vascular infiltration showed improvement after SAP-PRP injection. Immunofluorescence images showed that HSP-70 and caspase-3 were much less expressed in the SAP-PRP group than in the other groups. In conclusion, SAP-PRP can be effective in healing a rotator cuff tear by enhancing the collagen arrangement and inhibiting inflammatory changes and apoptosis. Copyright © 2015 John Wiley & Sons, Ltd.

Platelet-rich plasma in arthroscopic rotator cuff repair: a meta-analysis of randomized controlled trials

PURPOSE

The purpose of this study was to appraise the retear rate and clinical outcomes of platelet-rich plasma use in patients undergoing arthroscopic full-thickness rotator cuff repair.

METHODS

We searched the Cochrane Library, PubMed, and EMBASE databases for randomized controlled trials comparing the outcomes of arthroscopic rotator cuff surgery with or without the use of platelet-rich plasma. Methodological quality was assessed by the Detsky quality scale. When there was no high heterogeneity, we used a fixed-effects model. Dichotomous variables were presented as risk ratios (RRs) with 95% confidence intervals (CIs), and continuous data were measured as mean differences with 95% CIs. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was used to assess the quality of evidence for each individual outcome.

RESULTS

Eight randomized controlled trials were included, with the sample size ranging from 28 to 88. Overall methodological quality was high. Fixed-effects analysis showed that differences were not significant between the 2 groups in retear rate (RR, 0.94; 95% CI, 0.70 to 1.25; P = .66), Constant score (mean difference, 1.12; 95% CI, -1.38 to 3.61; P = .38), and University of California at Los Angeles (UCLA) score (mean difference, -0.68; 95% CI, -2.00 to 0.65; P = .32). The strength of GRADE evidence was categorized respectively as low for retear, moderate for Constant score, and low for UCLA shoulder score.

CONCLUSIONS

Our meta-analysis does not support the use of platelet-rich plasma in the arthroscopic repair of full-thickness rotator cuff tears over repairs without platelet-rich plasma because of similar retear rates and clinical outcomes.

LEVEL OF EVIDENCE

Level II, meta-analysis of Level I and II randomized controlled trials.

Rotator cuff tear: A detailed update

Rotator cuff tear has been a known entity for orthopaedic surgeons for more than two hundred years. Although the exact pathogenesis is controversial, a combination of intrinsic factors proposed by Codman and extrinsic factors theorized by Neer is likely responsible for most rotator cuff tears. Magnetic resonance imaging remains the gold standard for the diagnosis of rotator cuff tears, but the emergence of ultrasound has revolutionized the diagnostic capability. Even though mini-open rotator cuff repair is still commonly performed, and results are comparable to arthroscopic repair, all-arthroscopic repair of rotator cuff tear is now fast becoming a standard care for rotator cuff repair. Appropriate knowledge of pathology and healing pattern of cuff, strong and biological repair techniques, better suture anchors, and gradual rehabilitation of postcuff repair have led to good to excellent outcome after repair. As the healing of degenerative cuff tear remains unpredictable, the role of biological agents such as platelet-rich plasma and stem cells for postcuff repair augmentation is still under evaluation. The role of scaffolds in massive cuff tear is also being probed.

Arthroscopic double row cuff repair with suture-bridging and autologous conditioned plasma injection: Functional and structural results

Purpose:

The double row cuff repair with suture bridging is commonly used for arthroscopic rotator cuff repair (RCR). Despite its biomechanical qualities, the rate of iterative tears with this technique is important. The aim of our study was to evaluate the effect of autologous conditioned plasma (ACP) on functional results and on the rate of iterative tears after RCR by suture bridging.

Materials and Methods:

A consecutive series of 65 patients who underwent arthroscopic double-row suture bridge (Speed-Bridge, Arthrex) primary cuff repair of symptomatic full-thickness supraspinatus tear (retraction <3 in the Patte classification) were evaluated. Mean patient age was 60 (+/-8). The supraspinatus was repaired by knot-less bridging (SwiveLock, Arthrex) with suture tape material. 2 homogenous groups were created (A: 33 patients, B: 32 patients). In group A, all patients received, besides the cuff repair, an intra-tendinous ACP injection. Constant scores and Simple Shoulder Tests (SST) were measured pre-operatively and after a minimum follow-up period of 12 months post-operatively. Structural integrity of the repairs was evaluated by MRI according to the Sugaya classification. Sugaya >4 were considered as iterative tears.

Results:

Mean follow-up was 19 months (+/−42) in the 2 groups. The mean quantity of ACP injected was 6ml. (+/−1.5) and no specific complication of the injection was found. Mean preoperative Constant-Murley scores were 41,2 (±7,7) and 38 (±11)in group B. Mean normalized Constant-Murley score increased from 41 points (±7) pre-operatively to 70 points (±8) post-operatively in group A and from 38 points (±11) to 73 points (±11) in group B. There were no significative differences between the two groups (P > 0.05). In group A, 31 repairs were Sugaya 1-3 (94%), vs. 30 in group B (93%), and 1 was type 4 in group A (5%) vs. 2 in group B (8%).

Conclusion:

In both groups, RCR with suture bridging gave successful functional outcomes, with a low rate of iterative tear. In this preliminary study, the adjuvant effect of ACP injections could not be showed on both functional and structural results. Longer follow-up is needed to evaluate potential differences.

Platelet-rich plasma in rotator cuff repair: a prospective randomized study

BACKGROUND

Although platelet-rich plasma (PRP) has been used in rotator cuff repair, most authors have been unable to report the advantages of this method in clinical trials.

HYPOTHESIS

The use of PRP promotes better functional and structural results in arthroscopic rotator cuff repair.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

This was a prospective, randomized, double-blind study with 2 groups of 27 patients each (PRP group and control group). Complete supraspinatus tears with retraction of less than 3 cm were subjected to arthroscopic single-row repair; at the end of the surgical procedure, liquid PRP prepared by apheresis was given to the patients in the PRP group with autologous thrombin. The outcomes were assessed by the University of California at Los Angeles (UCLA) and Constant scales, visual analog scale (VAS) for pain, and magnetic resonance imaging (MRI) before and 3, 6, 12, and 24 months after surgery. The significance level was 5%.

RESULTS

The 2 groups of patients exhibited significant clinical improvement (P < .001). Between the preoperative assessment and 24-month follow-up, the mean UCLA score increased from 13.63 ± 3.639 to 32.70 ± 3.635 and from 13.93 ± 4.649 to 32.44 ± 4.318 in the control and PRP groups, respectively (P = .916). The mean Constant score increased from 47.37 ± 11.088 to 85.15 ± 9.879 in the control group and from 46.96 ± 11.937 to 84.78 ± 14.048 in the PRP group (P = .498). The mean VAS score varied from 7.00 ± 1.939 and 6.67 ± 1.617 before surgery to 1.15 ± 1.916 and 0.96 ± 2.244 at the 24-month assessment in the control and PRP groups, respectively (P = .418). The only difference was in the mean UCLA score at 12 months, with 30.04 ± 4.528 in the control group and 32.30 ± 3.506 in the PRP group (P = .046). The control group exhibited 1 case of a complete retear and 4 partial retears, and the PRP group exhibited 2 cases of partial retears (P = .42).

CONCLUSION

Platelet-rich plasma prepared by apheresis and applied in the liquid state with thrombin did not promote better clinical results at 24-month follow-up. Given the numbers available for analysis, the retear rate also did not change.

Degenerative disease in rotator cuff tears: what are the biochemical and histological changes?

The histopathological changes associated with rotator cuff tears include thinning and disorganization of collagen fibers, the presence of granulation tissue, increased levels of glycosaminoglycans, fibrocartilaginous metaplasia, calcification, fatty infiltration, and necrosis of the tendon margin with cell apoptosis. The biochemical changes include an increase in the expression of matrix metalloproteinases (MMPs) and a decrease in tissue inhibitor of metalloproteinases (TIMP) messenger ribonucleic acid expression. Histological evidence of tendinopathy has been found in patients with rotator cuff tear. Biochemical changes include significant increases in MMP1, MMP2, MMP3, and in TIMP1 and TIMP2 levels, not only at the lateral supraspinatus edge, but also in the macroscopically intact portion of the supraspinatus tendon and in the intact subscapularis. The tissue in the ruptured area of the supraspinatus tendon undergoes marked rearrangement at molecular levels. This involves the activity of MMP1, 2, and 3 and supports a critical role of MMPs in tendon physiology. Intact parts of the torn supraspinatus tendon can present the histopathological changes associated with rotator cuff tears. These findings suggest that biochemical changes can already occur in a macroscopically intact tendon and seem to point to a global degenerative process in the shoulder.

Does autologous leukocyte-platelet-rich plasma improve tendon healing in arthroscopic repair of large or massive rotator cuff tears?

PURPOSE

To evaluate the clinical and magnetic resonance imaging (MRI) outcome of arthroscopic rotator cuff repair with the use of leukocyte-platelet-rich plasma (L-PRP) in patients with large or massive rotator cuff tears.

METHODS

A comparative cohort of patients with large or massive rotator cuff tears undergoing arthroscopic repair was studied. Two consecutive groups of patients were included: rotator cuff repairs with L-PRP injection (group 1, n = 35) and rotator cuff repairs without L-PRP injection (group 2, n = 35). A double-row cross-suture cuff repair was performed by a single surgeon with the same rehabilitation protocol. Patients were clinically evaluated with the Constant score; Simple Shoulder Test score; University of California, Los Angeles (UCLA) score; and strength measurements by use of a handheld dynamometer. Rotator cuff healing was evaluated by postoperative MRI using the Sugaya classification (type 1 to type 5).

RESULTS

We prospectively evaluated the 2 groups at a minimum 2-year follow-up. The results did not show differences in cuff healing between the 2 groups (P = .16). The size of recurrent tears (type 4 v type 5), however, was significantly smaller in group 1 (P = .008). There was no statistically significant difference in the recurrent tear rate (types 4 and 5) between the 2 groups (P = .65). There was no significant difference between group 1 and group 2 in terms of University of California, Los Angeles score (29.1 and 30.3, respectively; P = .90); Simple Shoulder Test score (9.9 and 10.2, respectively; P = .94); Constant score (77.3 and 78.1, respectively; P = .82); and strength (7.5 and 7.0, respectively; P = .51).

CONCLUSIONS

In our study the use of autologous L-PRP did not improve the quality of tendon healing in patients undergoing arthroscopic repair of large or massive rotator cuff tears based on postoperative MRI evaluation. The only significant advantage was that the L-PRP patients had smaller iterative tears. However, the functional outcome was similar in the 2 groups of patients.

LEVEL OF EVIDENCE

Level III, case-control study.

Comparative effectiveness of platelet-rich plasma injections for treating knee joint cartilage degenerative pathology: a systematic review and meta-analysis

OBJECTIVE

To explore the effectiveness of platelet-rich plasma (PRP) in treating cartilage degenerative pathology in knee joints.

DATA SOURCES

Electronic databases, including PubMed and Scopus, were searched from the earliest record to September 2013.

STUDY SELECTION

We included single-arm prospective studies, quasi-experimental studies, and randomized controlled trials that used PRP to treat knee chondral degenerative lesions. Eight single-arm studies, 3 quasi-experimental studies, and 5 randomized controlled trials were identified, comprising 1543 participants.

DATA EXTRACTION

We determined effect sizes for the selected studies by extracting changes in functional scales after the interventions and compared the PRP group pooled values with the pretreatment baseline and the groups receiving placebo or hyaluronic acid (HA) injections.

DATA SYNTHESIS

PRP injections in patients with knee degenerative pathology showed continual efficacy for 12 months compared with their pretreatment condition. The effectiveness of PRP was likely better and more prolonged than that of HA. Injection doses ≤2, the use of a single-spinning approach, and lack of additional activators led to an uncertainty in the treatment effects. Patients with lower degrees of cartilage degeneration achieved superior outcomes as opposed to those affected by advanced osteoarthritis.

CONCLUSIONS

PRP application improves function from basal evaluations in patients with knee joint cartilage degenerative pathology and tends to be more effective than HA administration. Discrepancy in the degenerative severity modifies the treatment responses, leading to participants with lower degrees of degeneration benefiting more from PRP injections.